From Wikipedia, the free encyclopedia Health care fraud
Health care fraud
Health Care Fraud includes health insurance fraud, drug power-assisted wheelchair while only giving the patient
fraud, and medical fraud. a manual wheelchair.[4]
Health insurance fraud occurs when a company or
an individual defrauds an insurer or government health Duplicate Claims
care program, such as Medicare (United States) or equiv- In this case a provider does not submit the exact same
alent State programs. The manner in which this is done bill, but changes some small portion like the date in order
varies, and persons engaging in fraud are always seeking to charge Medicare twice for the same service rendered.
new ways to circumvent the law. Damages from fraud can Rather than a single claim being filed twice, the same ser-
be recovered by use of the False Claims Act, most com- vice is billed two times in an attempt to be paid twice.[4]
monly under the qui tam provisions which rewards an in-
dividual for being a "whistleblower", or relator (law).[1] Unbundling
Bills for a particular service are submitted in piecemeal,
Recent News and Statistics that appear to be staggered out over time. These services
would normally cost less when bundled together, but by
The FBI estimates that Health Care Fraud costs American
manipulating the claim, a higher charge is billed to Medi-
tax payers $60 billion a year.[2] Of this amount $2.5 billion
care resulting in a higher pay out to the party commit-
was recovered through False Claims Act cases in FY 2010.
ting the fraud.[4]
Most of these cases were filed under qui tam provisions.
Over the course of FY 2010, whistleblowers were paid a
total of $307,620,401.00 for their part in bringing the cas-
Excessive Services
es forward.[3] Occurs when Medicare is billed for something greater
than what the level of actual care requires. This can in-
clude medical related equipment as well as services.[4]
Types of Fraud
There are several different schemes[4] used to defraud Unnecessary Services
the Health care system. Unlike excessive services, this fraudulent scheme occurs
• Billing for services not rendered when claims are filed for care that in no way applies to
• Upcoding of services the condition of a patient, such as an echo cardiogram
• Upcoding of items billed for a patient with a sprained ankle.[4]
• Duplicate claims
• Unbundling Kickbacks
• Excessive services
Kickbacks are rewards such as cash, jewelry, free vaca-
• Unnecessary services
tions, corporate sponsored retreats, or other lavish gifts
• Kickbacks
used to entice medical professionals into using specific
medical services. This could be a small cash kickback for
Billing for services not rendered the use of an MRI when not required, or a lavish doctor/
Often done as a way of billing Medicare for things that patient retreat that is funded by a pharmaceutical com-
never happened. This can involve forging the signature pany to entice the prescription and use of a particular
of those enrolled in Medicare, and the use of bribes or drug.[4]
"kickbacks" to corrupt medical professionals.[4] People engaging in this type of fraud are also subject
to the federal Anti-Kickback statute.
Upcoding of services
Billing Medicare programs for services that are more
costly than the actual procedure that was done.[4]
Examples of Fraud Cases
In the case United States ex rel. Donigian v. St. Jude Med-
Upcoding of Items ical, Inc., No. 06-CA-11166-DPW (D. Mass.) St. Jude Med-
ical, Inc. agreed to pay $16 million to quiet allegations
Similar to upcoding of services, but involving the use of
of paying kickbacks to physicians. The whistleblower was
medical equipment. An example is billing Medicare for a
able to provide detailed insider information as to the na-
ture of the kickbacks, which ranged from entertainment
1
From Wikipedia, the free encyclopedia Health care fraud
to sporting event tickets and other gifts. The relator in [2] "FBI-Health Care Fraud". FBI. http://www.fbi.gov/
this case was awarded $2.64 million.[5][6] about-us/investigate/white_collar/health-care-
The case United States et al., ex rel. Jim Conrad and fraud.
Constance Conrad v. Forest Pharmaceuticals, Inc, et al., [3] "The Department of Justice Health Care Fraud and
No. 02-cv-11738-NG (D. Mass.) involved a drug manufac- Abuse Control Program Annual Report for Fiscal
turer selling a drug, Levothroid, that had never been ap- Year 2010". Department of Justice. 2010-01-24.
proved by the FDA. These allegations settled for $42.5 http://www.justice.gov/dag/pubdoc/
million due to multiple whistleblowers stepping forward hcfacreport2010.pdf.
to provide detailed information on the alleged fraud. The [4] ^ "Financial Crimes to the Public Report 2006". FBI.
collective reward to the relators in this case was over 2006. http://www.fbi.gov/stats-services/
$14.6 million.[7][8] publications/fcs_report2006/financial-crimes-
report-to-the-public-fiscal-year-2006#Health.
Reporting Fraud [5] "St. Jude Medical, Inc. Settlement". PRWeb.
2011-01-21. http://www.prweb.com/releases/
There are many ways to report cases of fraud. If a patient 2011/1/prweb8082432.htm.
or health care provider believes they have witnessed [6] "Justice News". Department of Justice. 2011-01-20.
Health Care Fraud, they are encouraged to contact the http://www.justice.gov/opa/pr/2011/January/
FBI via either their local office, telephone, or the online 11-civ-078.html.
tips form. [7] "Forest Whistleblower Cases Settle for Over $300
If, however, they want to ensure the government ac- million". PRWeb. 2010-09-15.
tively investigates the alleged fraud, they are encouraged http://www.prweb.com/releases/2010/09/
to contact legal counsel from an experienced firm that prweb4525334.htm.
specializes in qui tam litigation under the False Claims [8] "Drug Maker Forest Pleads Guilty". Department of
Act. A good legal team can advise potential whistleblow- Justice. 2010-09-15. http://www.justice.gov/opa/
ers of their rights, protections, and what evidence is nec- pr/2010/September/10-civ-1028.html.
essary to solidify a case against the group leading the
fraud.
External Links and Resources
See also 1. Masterminds Behind Pharmaceutical Fraud Deserve
Prison Time
• Medicare fraud 2. The Future of the False Claims Act
3. CGMP Violations may be the Basis for Qui Tam
References 4. Blowing the Whistle on Health Care Fraud
5. Health Care Fraud Prevention
[1] "Department of Justice". Department of Justice. 6. FBI Tips Online
http://www.justice.gov/usao/tne/
health_care.html.
Retrieved from "http://en.wikipedia.org/w/index.php?title=Health_care_fraud&oldid=449154449"
Categories:
• Fraud
• Healthcare in the United States
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